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SEP-49-2%11 10 : 19 AM WALKER, OOFING 6512510916 P. 01 <br /> --� • ---•-;- - •rl�•� 1w, 1namzenance Renovation <br /> (windows, doors, siding, re-roof, etc. <br /> O� Mailing Address. <br /> PO Box 08 Permit number: v?D//--O// 8 <br /> Crystal Bay, MN 55323-0066 Data received: <br /> Sheat Addross, Received by: <br /> 2750 Orono Kelley <br /> Parkway <br /> _- 358 Plan review fee; , <br /> Main: 952.249-4000 Fox, 852-249-4618 v�yyy,cl.orono.rnn.ua <br /> Total Fee: �'� <br /> This application form must be completed in full and all required Information must be b ed. <br /> GENERAL INFORMATION: <br /> Incomplete applications will be returned, (Please pry'ny <br /> 1 <br /> Job Site Address: 1 5Lrwoero tmv P_ <br /> WIII this be a Parade ofHomes, Remodelere Showcase Home or other Display Home? Y� <br /> lI yw,a spedel eventP&M1t 18 roqu'md wth Pocks Depertnront and City Counell epprayal eo days pNor!o the event ShutNe bus asnr►ee Will be <br /> nhqulrod unless epplioent demonstrates auAtC/enf on-8ne perking/s avellabh, Nan-permgEed ownta wfl not be Mous s <br /> CONTRACTOR/APPLICANT INFORMATION: <br /> Name: A <br /> State License# 4 slA Expiration Date: <br /> Lead Certlficstlon Number: r_ j _ — I-?.- <br /> (Por work on homes that were conebuceed PAC <br /> to 7a7Q ExP1tathon flats: <br /> Phone; ( — I - p 0— offs <br /> Mailing Address: City, (cell) <br /> Contact Person: l4lJ(� ZIP: , S <br /> �Q n / Homeowner (ciroa on,) <br /> Email and/or Fax: Applicant Is: <br /> PROPERTY OWNER INFORMATION: <br /> Name: %A59— <br /> Phone(day): qs2-s4 /` w 19 655 <br /> Address; &v-4�TDWA) City; 06 ZIP: 59 <br /> Email and/or Fax <br /> PROJECT INFORMATION: <br /> ype of Project; <br /> Any earth movement may require <br /> ❑Door(s) ❑Remodel ❑ Fire Damage MCWD review&permits: <br /> e-roof,asphalt ❑ Repair Mlnneheha Creek Watershed District(MCWD) <br /> ❑ Storm Damage 18202 Minnetonka Blvd <br /> ❑ Re-roof,cedar Restoration Dee haven, MN 56391 <br /> ❑ El Damage Phone: 952471.0590 <br /> ❑Re-roor,other(speclty) ❑Siding ❑Other: (specify) Fax; 952.471-0862 <br /> ❑Window(s) www.nllnn$hahecreek ora <br /> Overall Pro ect Description: 1z" tf <br /> Estimated Construction Valuation of Project(excluding land) $ / 14 5d o0 <br /> r <br /> APPLICANT ACKNOWLEDGEMENT; <br /> • Agrees to provide all Information required or requested by the Building Department; <br /> • Certifies that the Information supplied Is true and correct to the best of his/her knowledge. The applicant recognizes that they <br /> are solely responsible for submitting a complete application being aware that upon failure to do so, the staff has no alternative <br /> but to reject it until It Is complete; <br /> • Some or all of the Information that you are asked to provide on this application Is classified by State low as either private or <br /> confidentfel. Private data is information which generally cannot be given to the public but can be given to the subject of the <br /> data. Confidential data Is Information which generally cannot be given to either the public or the subject of the data. Our <br /> purpose and Intended use of this information is to annually update our records and records of other governmental agencies <br /> required by law. If you refuse to supply the info ation.thea lication may not be issued. <br /> Applicant's Signature: Date: S <br /> Leat Updated: 09.00.2011 <br />